NICE | The National Institute for Health and Care Excellence



Business case:

Occupational Therapy Service redesign to include self- management groups

Following the increased demand on the palliative care Occupational Therapist who previously served Adelaide ward they recognised the need to have a dedicated OT for Oncology and Haematology patients, making flexible use of their budget to turn a nursing post into a full-time therapist. Within an acute setting, Occupational therapists traditionally focus on assessing and planning for hospital discharge. Having a full-time therapist gave more time to address the holistic needs of the patients though priorities for this were not defined and offered much flexibility to deliver this.

Fitting in with the trust objectives and strategy to provide excellent and resourceful care we set out to look at the most effective way of adding value to the stay of the patient. In order to do this we looked at feedback from patients about their stay using friends and family card comments, visited other trusts to see what they were providing, researched best practice, met as a forum to decide which of these were in our power to provide and created questionnaires to see which aspect we should focus on first. develop the service going on from there.

From looking at best practice guidelines to gauge external factors for this change, NHS England guidelines for Cancer services (2016) state that every individual should be offered the opportunity to attend health and wellbeing events to enable self-management of their condition.

Patients are able to choose where they receive their treatment so by implementing service improvements we are able to develop a competitive advantage over other hospitals and gain recognition as a centre for excellence; this in turn will have an impact upon our recruitment, retention and visibility within the market-place all of which are key strategic objectives within the trust strategy: Vision 2025 (Royal Berkshire Hospital 2018).

Changing the current delivery of Occupational therapy services for oncology patients would aim to improve the quality of the service patients receive in line with one of the trust’s strategic priorities ‘Provide the highest quality care’. It also aims to reduce the levels of anxiety at point of discharge which can help to reduce bed days and prevent further hospital admissions by giving the patients skills to manage their own symptoms better (Ryan 2017). This would work towards creating long term financial stability and also transformation of the service (Royal Berkshire Hospital 2018). These links can also be seen within the clinical care strategy with development of highest quality care within acute oncology is specifically identified as a clinical priority (Royal Berkshire Hospital 2018b). Elements from this project also extend to meet aspect of the quality and transformation strategy though the focus is on creating high quality care and adding value for the patient.

To gain information to direct this change we completed a market analysis; including analysis of the current offerings of other care settings, respond to comments made about care received on the ward through friends and family feedback, use a questionnaire to determine value to the patient and co-create a service with these stakeholders that meets their needs, and look at relevant clinical evidence about improving health and wellbeing of patients with cancer (Said 2015, Dawar 2013).

We found that other hospitals and palliative care settings were utilising their skills to deliver a range of services such as fatigue management, relaxation sessions and aromatherapy in order to improve patients health and wellbeing as well as managing anxiety so ensuring that we are also providing these services in order to remain competitive is vital.

Through the questionnaires it was identified that managing anxiety was the highest unmet need of patients affecting their confidence about leaving hospital and managing at home. Other aspects of need included fatigue and breathlessness. However, staff felt that exercise was the highest priority for patients. By using a co-creation method, it can increase the level of competitive advantage gained (Francis 2014, Bettencourt 2014) Though there has to be considerations not to over-compromise on other areas to deliver on value-based services and make best use of resources.

With the information gained a plan was made regarding the new operation process meeting jointly with heads of Occupational Therapy, Physiotherapy, Ward manager and the Clinical lead.

Due to the output of the ward sessions could be repeated with a relatively high turnover rate to ensure that all patients had the opportunity to attend, this would initially be one session every two weeks with the addition of further sessions once the initial programme is established. Due to the high level of demand for anxiety management a relaxation and anxiety management session will be first as a trial with questionnaires provided before and after to measure levels of anxiety and confidence in self-management before and after the sessions.

Adding variety to these sessions will increase the complexity of operational delivery though many of the skills needed to deliver these sessions are transferable and follow the same format as other established programmes to ease this burden.

With regard to variability of demand, the ward has only 16 beds and not all patients are appropriate at all times so this may not be as much of an issue. If there are a high number of patients all requiring the same session, there is scope for flexibility in meeting a variable demand by providing extra sessions. (or integrating these into one to one sessions)

If the therapist delivering the sessions is unwell or on annual leave it will be assessed by the lead OT and Physio as to whether the session is provided cover across the therapy team or whether it is cancelled depending on clinical need of the rest of the hospital.

There is a high level of visibility and face to face time required due to the nature of delivering a group though it is likely to create greater visibility to a larger number of patients as they can receive the session simultaneously eliminating task duplication.

As there is a difference in determining the value of services rather than goods (Kuzgun 2015) in order to measure the change data will be collected from the patients about how they feel before and after the session. There are national overall cancer care satisfaction scores and it would be interesting to see whether these also have an effect after implementing this change, but a separate measure would be beneficial to measure the session without other external factors.

As already discussed, the ‘product’ which is actually a service (Kotler 2016), will take the form of an oncology focused, group-based forum and education session designed to give patients the tools to self-manage their condition upon discharge. It is both requested by the patients throughout the consultation questionnaires and also prevalent within best practice literature.

Although there is no cost to the patient in attending these sessions there is a time consideration that the patient may not be able to access therapist time which is now utilised by running the groups. This method of service delivery would have small running costs such as paper for information sheets, aromatherapy or exercise equipment and promotional materials. Printing costs will be covered by the ward and all other items have had agreement from league of friends and Macmillan cancer support to purchase these. There is a cost implication to the occupational therapy team in terms of the amount of time required to set up, run, evaluate and continue to develop the groups. Currently the staff member working on Adelaide is assisting junior members of staff and has a role in covering for sickness and absences within the team. Other members of the team have agreed to be able to support juniors to ensure that time is given to implementing this service.

The sessions will be completed with inpatients within a room just outside the oncology ward though there is scope to widen this service to other patients with a cancer diagnosis on different wards or even to implement sessions for outpatients who would benefit from sessions to maintain their health and wellbeing at home potentially preventing hospital admissions. This is not currently in line with the strategy objective to deliver care closer to home though these sessions could be developed in community hubs in the future, so the budget provided later on is to show the complete cost of providing the service if bought in by others.

The Occupational Therapist, Physiotherapist and nursing team will all be able to promote sessions to patients and posters around the ward will advertise the available sessions. There are also patient feedback whiteboards around the ward which will provide opportunity to advertise other sessions coming up. Visibility will also take the form of communications though the trust newsletter, clinical forums and a poster will be completed and presented about the results of reducing anxiety for patients.

This visibility will also promote our hospital as a centre for excellence and make the trust more attractive to patients, current staff and as a tool in attractive prospective employees this would also feed into our recruitment and retention strategy

Budget - 1st year projected running costs. As previously noted, there is no requirement for extra staffing to cover these sessions as therapy time is already available but is to be reorganised to better suit the needs of the patients. The costs for therapists are purely for demonstration if the service were to be set up within another area and needed to be provided with a cost.

This is based upon on 26 sessions per year bi-weekly sessions with 4-6 participants

| |Outlay |Price per session |Total |

|Printing |- |5p x 5 |£0.25 x 26 |

|2 x A4 double sided per hand | |£0.25 |= £6.50 |

|out at 5 p per sheet | | | |

|Staff |Approx 10 hours |2 hours band 6 therapist 1-hour group |session cost x number of |

| |Band 6 and Band 7 to complete |session plus set up and notes (calculated|sessions |

| |questionnaire distribution analysis|on mid-point band 6) |£51 x 26 |

| |and set up service |£15.96 per hour = £31.92 |= £1326 |

| |(calculated on mid-point bandings) |2 hours band 3 assistant to support |set up costs |

| |Band 6 £15.96 per hour = £79.80 |during session bring patients to group |= £1501.08 |

| |Band 7 £19 per hour = £95.28 |and return to ward (calculated on | |

| | |mid-point band 3) | |

| |£175.08 |£9.52 per hour = £19.08 | |

| | |£51 | |

| | |(Set up cost spread per session £6.73) | |

|Aromatherapy diffuser |£15 |£0.58 |£15 |

|Oils |£1.45 per 5 ml |0.5 ml use per session |(0.5 X 26)/5 |

| | |= £0.14 |15 bottles per year |

| | | |= £21.78 |

| | | |Total |

| | | |£1544.36 |

For comparison:

The equivalent cost of having 1 hour 1:1 sessions with average 5 patients plus 30 mins per note entry

£15.96 x 7.5 hours (x 26 weeks)

119.70 x 26 = £3112.20

This would create a cost saving on average of £1567.84 per year

so, this method of service delivery is far more efficient even with the high set up costs.

Time frame

|September |Investigate other agencies offerings |

|End Sept |Research best practice |

|Mid October |Initial meeting with oncology team |

|End Oct |questionnaire development |

|Early November |questionnaire release and return |

|December |Analyse questionnaire results |

|January |Develop programme |

|End Jan |Start implementing |

|Feb |Collate results |

| |Evaluate |

| |Make changes as needed |

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